Request for possible employment

Thank you for taking the time to complete this form. Please note that this is not a job application.
The questions in red bold lettering are required and you must provide that information.

First Name		Last Name
Address Line 1
Address Line 2
City		State	Select state Delaware Maryland Pennsylvania Virginia West Virginia Washington D.C.
Zip		Email
Day Phone		Evening Phone
example: (301)123-4567 ext.1234		example: (301)123-4567 ext.1234
Best time to call
How did you learn about us?
Have you been employed by an Autism Waiver Provider?	Yes No
Have you been employed by a DDA Provider?	Yes No
When Can You Start?
How far can you commute to work?	5 miles 10 miles 15 miles 20 miles or more
What days and times are you interested in working?
What position(s) are you applying for? Check all that apply.	Family Consultant Supervisor Program Manager Intensive Individual Support Technician Respite Care Worker Adult Life Planner Therapeutic Integration Technician
What is the highest level of education?	GED High school diploma Some college AA Degree BA Degree BS Degree Some Graduate School Masters Degree Doctoral Degree
If you have a Masters or PhD, what is your field? Check all that apply.	Education Child Studies Psychology Social Work Nursing Occupational Therapy Speech/Language Pathologist
Other, please specify:
Do you have professional certifications? Check all that apply.	Psychologist Special Educator Speech Therapist Behavioral Analyst
Other, please specify:
Do you have professional licensures? Check all that apply.	Psychologist Social Worker Nurse Psychotherapist Speech Therapist Professional Counselor Marriage and Family Therapist Occupational Therapist
What time frame best describes your total amount of experience supporting/serving children/teens with autism? CHOOSE ONE...and be sure the length of time of your experience can be documented.	No experience Less than 3 months 3 to 6 months 7 to 9 months 10 to 12 months 1 to 2 years 3 to 4 years 5 to 9 years 10+ years
Which category(s) best describes your current or past experience involving individuals with Autism or Developmental Disabilities (Click all that apply)	I have experience as a Professional (certified special education teacher, licensed speech therapist, behavioral specialist, psychologist, etc.) in public and/or private school I have experience as a Supervisor of Direct Care Staff, as a Professional I have experience as a Paraprofessional, as a teacher's assistant or one-to-aide in a special education class room or an inclusive school setting in a public and/or private school I have experience as a direct care worker at a Residential facility I have experience as a Parks and Recreation support technician who serves children with autism or with developmental disabilities I have experience as a Bus Aide (employed by a school or rehab program) providing one-to-one support to children with autism or with developmental disabilities I have experience as a Day Care Worker who cared for children with autism or with developmental disabilities I have experience as a Respite Care Worker for children with autism or with developmental disabilities I have experience as a Baby/Child Sitter caring for children with autism or with developmental disabilities I have experience as a Home- and Community Based Program Technician hired by an agency and I provided one-to-one support to children with autism or with developmental disabilities I have experience as a Home- and Community Based Program Technician hired privately by a family and I provided one-to-one support to children with autism or with developmental disabilities I have experience as a Professional directing older adolescents/adults through the Transition Process in order to access Adult Services in conjunction with service coordinators and the Department of Developmental Disabilities I have experience as a Supportive Employment Technician or Job Coach who provided direction to an individual with autism or other developmental disabilities I have experience as a direct care worker who worked for Another Autism Waiver Provider I have experience as a Volunteer Worker serving children who have autism spectrum disorders or developmental disabilities I live/have lived with a Family Member who has an autism spectrum disorder or other developmental disability I have at least 25 hours of College Credits related to autism spectrum disorders or developmental disabilities In addition to or instead of what is listed above, I Have Other Type(s) of Experience with a children with autism or with developmental disabilities which I will describe in the comment box 'Tell Us About Yourself' at the end of this skills profile. None of the above categories apply to me
If you have a “special skills” certificate, What is it? Check all that apply.	First Aid Infection Control CPR Medication Administration Training in Seizure Management Behavior Principles and Strategies Managing Difficult Behaviors
Other, please specify
Check any trainings that you were required to complete if you were employed by a DDA provider Check all that apply.	Community Integration and Inclusion Individual-Directed, Outcome-Oriented planning for individuals general characteristics and needs of individuals served Fundamental rights of individuals and families making choices Communication Skills First Aid Blood Bourne Pathogens
Other, please specify
In what areas, if any, have you served individuals with autism? Check all that apply.	Life Experience Day Care Other Autism Waiver Provider Home-Based Autism Program Paraprofessional in school-based program Professional in school-based program Center-based program Private school setting Public school setting Job Coaching program
Other, please specify
What were/are the ages of individuals with autism you have provided services to? Check all that apply.	5-8 yrs old 9-12 yrs old 13-15 yrs old 16-18 yrs old 19-21 yrs old 22-30 yrs old 31-45 yrs old 46-60 yrs old Over 61 yrs old
What were/are the ages of individuals in general you have provided services to? Check all that apply.	5-8 yrs old 9-12 yrs old 13-15 yrs old 16-18 yrs old 19-21 yrs old 22-30 yrs old 31-45 yrs old 46-60 yrs old Over 61 yrs old
What special skills for autism programming have you received training in?	Sign Language Picture Exchange Communication System (PECS) Augmentative Communication Music Therapy Adaptive Physical Education Art Therapy Movement Therapy Discrete Trials Applied Behavioral Analysis (ABA) Verbal Behavior (ABBLS) Natural Environment Learning (NET) Use of a Behavior Intervention Plan The TEACCH Program Not Sure None
Other, Please specify:
Tell us about yourself and explain why you believe you would be an asset to The Whole Self Center.